Intervention Cut Use of Possibly Unsafe Drugs

by David Pittman David Pittman,Washington Correspondent, MedPage Today
January 24, 2013

Educating physicians on potentially inappropriate medications lowered prescription of such drugs to seniors by nearly a third in 3 years, a proof-of-concept study showed.

Exposure to potentially inappropriate medications dropped in those 65 and older from 7.8% at baseline to 5.3% after general practitioners (GPs) in Italy received information on prescribing for older patients (P<0.001), according to the study, published in the December issue of the journal Drugs & Aging.

Reduction in such prescribing was greater in the intervention group than in the control group, in which use of potentially inappropriate medication declined from 7.7% to 6.1%, Scott Keith, PhD, of Thomas Jefferson University in Philadelphia, and colleagues found.

The study of roughly 80,000 elderly patients resulted in 608 seniors (12.4% of the number expected) being spared an exposure to drugs that might be inappropriate during the final quarter of the 3-year study, results stated.

"Although the prescribing of drugs identified as [potentially inappropriate medications] for older people is unlikely to disappear completely, the intervention appears to have had a lasting impact," the authors wrote. "By reaching out to GPs and maintaining contact with them, this quality intervention appears to have positively impacted physicians' awareness and prescribing behavior, which led to significant reductions in [potentially inappropriate medication] exposures and likely translated to significant population health benefits among their older patients."

Potentially inappropriate medications were defined as prescription or over-the-counter drugs having adverse risks exceeding their health benefits when compared with alternative therapies. Nearly a third of all prescription drugs in the U.S. are for those 65 and older, and preventable medication errors in outpatients cost $4.2 billion a year, the study noted.

Keith and colleagues used the Beers Criteria from the American Geriatrics Society to develop their list of potentially inappropriate medications, refining it to 23. Examples included nonsteroidal anti-inflammatories, atypical antipsychotics, and digoxin.

Rather than focusing on patient behaviors, the researchers sought to change the prescribing practices of physicians. They worked with colleagues in Italy because that country offers universal health coverage, providing an easier forum to study.

"We have learned that in order to be effective, an intervention should be designed as a combination of educational strategies, including a proactive dissemination of material via consistent peer-to-peer interactions," the authors wrote. However, "we are not aware of any previous research that would indicate that any particular component of our intervention is likely to be of greater importance than any other."

They provided 303 general practitioners in the Local Health Authority in Parma, Italy, with three quality improvement interventions:

A list of medications to always be avoided, along with a list of alternative drugs

Seniors exposed to potentially inappropriate medications had shorter time to their first hospitalization, more frequent acute hospitalizations, and more adverse reactions than those not given such prescriptions, the investigators found.

Other interventions have used various strategies including those used by the current researchers, but have yielded mixed results, the authors noted.

The study attributes its success to a combination of educational strategies and nonpunitive approaches. Also, the authors noted that their list was less rigid than the Beers Criteria, leading prescribers to be more willing to incorporate suggestions into their practices.

The authors said their interventions didn't place a substantial burden on participating providers, and results can be applied to other settings with a reasonable likelihood of success.

"Further study of GP characteristics could reveal subpopulations of GPs most likely to respond favorably to interventions," they noted.

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